A New Field of Geriatric Oncology, Under Construction

Dr. William Dale talks with a patient in his geriatrics clinic (photo by Bart Harris)

Creating a new research field doesn’t happen overnight. It requires bringing together like-minded researchers willing to push out into the unknown, funding agencies willing to be convinced that the new field is worth of grant dollars, and some semblance of an overall plan so that those efforts and dollars are put to optimal use. Soldering together a new field out of two existing fields can save some of the groundwork, but also creates its own set of obstacles, as representatives from each pre-existing discipline maneuver for common ground with their colleagues from across the fence.

The very young field of geriatric oncology, the study of cancer and cancer treatments in the elderly, has already jumped some of those hurdles. Most importantly, the field has a very good reason to exist, as cancer is primarily a disease of the elderly, and the U.S. population is growing increasingly older as baby boomers reach retirement age. Clinics focused on the care of elderly patients with cancer have sprung to life, including the SOCARE Clinic at the University of Chicago Medical Center. Yet there remains a void of knowledge about how cancer forms, grows, and can potentially be cured in older patients, due to clinical trials that enroll primarily younger subjects. Filling that void – and creating a field to do so – was the focus of a two-day conference last weekend at the Hilton O’Hare, where 50 members of the newly-formed Cancer & Aging Research Group discussed the fine details of how best to proceed.

Two numbers presented by NYU’s Daniel Gardner and echoed by several others demonstrated the need for geriatric oncology research: 61 percent of new cancer cases occur in people older than 65, but only 25 percent of patients on cancer clinical trials are from that age group. What’s more, the elderly that do make it into trials of new drugs and therapies are a special breed – “Olympic athletes” that meet strict enrollment requirements designed to pick research subjects that are largely free of co-morbid health conditions beyond their cancer. That leaves physicians in the dark about how to treat less healthy elderly cancer patients, with no evidence to guide their treatment decisions.

“For the vulnerable and frail adults, there’s so little data…it’s a really big population that’s coming to the clinic right now, where almost every patient I see I don’t have the right kind of evidence for,” said Supriya Mohile from the University of Rochester, who organized the conference with Arti Hurria from City of Hope Hospital in California and William Dale, section chief of geriatrics and palliative medicine at the University of Chicago.

One central question of the conference was whether to remedy that shortage by designing clinical trials specifically for older patients or by lobbying clinical researchers to include more elderly subjects in trials. Both solutions hinge upon improving recruitment rates for elderly patients, the burden of which often falls on the researchers themselves. In a talk titled “We Have Met the Enemy, and it is Us,” University of Chicago assistant professor Blase Polite showed data from several studies showing that patients older than 65 are typically half as likely to be offered an experimental cancer treatment. When elderly patients are offered the chance to enroll in a clinical trial, they are as likely – if not more so – as those under 65 to say Yes, he found.

The gap in enrolling elderly patients in clinical trial may stem from a larger problem of physician-patient communication, many presenters argued. Decisions about cancer treatment are certainly different for a 45-year-old vs. a 75-year-old, and a patient’s weighing of treatment side effects, quality of life, and the chance of a cure may change with age. But as Northwestern’s Linda Emanuel argued, physicians need to better understand that internal calculus for elderly patients facing the possibility of death.

“[There are] gratifications that are unique to those that are facing the end of life, through age or through cancer or through other terminal conditions,” Emanuel said. “What is that kind of wellbeing? I don’t think we know, we in the research field. We don’t have measures for it and we don’t have methods for it.”

The scant data that does exist on cancer and cancer treatments in the elderly suggests intriguing and clinically relevant differences. Several presenters referred to Hyman Muss‘ clinical trial of elderly breast cancer patients as a sterling example of the kind of research that is sorely needed; his 2009 study found that standard chemotherapy was an effective treatment in older women, while more aggressive chemotherapy produced substantial toxicity.

“Just to know in an older population a little bit about the toxicity and the effectiveness is extremely helpful,” said Muss, a professor of medicine at the University of North Carolina, Chapel Hill.

Incremental progress is also being made on the basic science end, where some laboratories studying the biological mechanisms of cancer have started using older animals to model the disease. Judith Campisi, who studies aging and cancer at the Buck Institute in California, said that inflammation may be the common factor that explains increased incidence of cancer in the elderly. But the lack of communication between aging and cancer researchers has created difficulties in translating laboratory research to the clinic, she said.

“I think part of the problem is that people who study cancer don’t work on older animals, and people who study aging don’t work on cancer…they’re viewed as two different disciplines.” Campisi said. “People who study cancer will work on their pre-clinical model in young animals, and then they fail in the clinic and it’s a big surprise.”

Rare is the conference where the to-do list so far outpaces the amount of actual data, but the uncertainties in the presentations made for more vibrant discussions than usually encountered in a room full of scientists. With opinions coming from oncologists, geriatricians, psychologists, ethicists, nurses, social workers, and laboratory scientists, it was predictably hard to reach a hard consensus in the hours allotted. But all agreed that the time has come for a unified geriatric oncology effort, and there was no shortage of investigators, young and old, eager to execute such research. Creating a new field doesn’t happen in two days either, but where there’s momentum and fruitful discussion, good science will usually follow.